JAMA 9 Sep 2009 Vol 302
1059 Do you solemnly swear to abide by the principle of using antibiotics only when strictly necessary? At present it’s easy to mutter assent to visiting bacteriologists and prescribing advisers, on the basis that only we ourselves can decide when it’s strictly necessary. If little Shane has a nasty cough and it’s 7 on a Friday evening, then strict necessity determines that he gets some amoxicillin and that you go home to dinner. But all this might – perhaps – change when we get a point-of-care test that enables us to determine which patients have bacterial infections and which don’t. The front runner for this is serum procalcitonin, and some of you may remember a study from Swiss primary care showing its usefulness in adults with lower respiratory infections which appeared in the Archives of Internal Medicine last year. The same investigators ran a parallel study called ProHOSP which as its name implies tested out procalcitonin in hosp. Here they report the results from six tertiary hosps where patients with LRTI – community acquired pneumonia, acute bronchitis, or exacerbation of COPD – were randomised to receive antibiotics based on standard guidelines or procalcitonin (PCT) levels at presentation and at days 3, 5, 7, and discharge. There was a large drop in antibiotic use in the PCT guided group with no difference in clinical outcomes.
1084 There’s a new book out called The Emperor’s New Drugs: exploding the antidepressant myth which points out the speculative and self-contradictory nature of the biochemical theories on which modern antidepressant treatment is based. That, however, is a very different thing from showing that the drugs don’t work. The same thing seems to be happening in the field of attention-deficit/hyperactivity disorder (ADHD) which scarcely existed as a diagnosis until about 20 years ago. Positron emission tomography seems to indicate a reduction in dopamine synaptic markers in adults with ADHD. Expect a flurry of trials of dopaminergic drugs, or conversely dopamine-blocking drugs, in adults with ADHD (kids are too tricky to do trials on) with high drop-out rates and exaggerated claims of benefit.
NEJM 10 Sep 2009 Vol 361
1045 Over the last couple of years, we’ve heard a lot about the drawbacks of clopidogrel, which is soon going to come off patent, and the possible merits of prasugrel, which has just been licensed to compete in the highly lucrative antiplatelet therapy market. You could call it the Quest for the Holy Grel. But now comes ticagrelor, which has the dual advantage of being independent of the CYP metabolism pathway and reversible in its action on the platelet PY12 receptor. In the PLATO study comparing it with clopidogrel following acute coronary syndromes with and without ST elevation, ticagrelor produced better outcomes for overall mortality, stroke and myocardial infarction without an increase in major bleeding. But the trick will be to apply this knowledge to individual patients, as the editorial (p.1108) states, in accordance with a great principle from Plato himself: “A good decision is based on knowledge, not on numbers”. Plato also said that attention to health is life’s greatest hindrance, with which I heartily concur.
1067 We are walking microbiology laboratories. Not only are there more bacteria in our gut than cells in our bodies, but millions of our own cells contain viruses that live in quiet equilibrium with our own DNA and RNA. So there was something quite unsettling when the first cases of progressive multifocal leukoencephalopathy (PML) were reported in patients receiving natalizumab for multiple sclerosis. By a cruel irony these patients died from rapid demyelination brought about not by MS, but by a virus that had lain harmlessly dormant in their own bodies, as it may well do in everybody: the polyomavirus known as JC. As a result, natalizumab had its licence withdrawn for a time, but was then relicensed for cautious use in patients with rapidly relapsing MS. PML continues to occur in one per thousand of these patients, but from this study we know that subclinical JC reactivation occurs in the majority (63%) of MS patients treated with natalizumab. In the unfortunate few who get the full-blown syndrome (14 so far in MS treatment across the world) it is now possible to arrest its fatal course by plasma exchange, though this is followed by a life-threatening immune reconstitution inflammatory syndrome.
Lancet 12 Sep 2009 Vol 374
881 One of the things (though I can’t think of the other) that The Lancet does best is to publish global health surveys. Mortality in young people (aged 10-24) has been little studied but this big WHO/MRC study changes that. The WHO stratification of countries by income is decidedly broad-brush, with Poland and Burkina Faso falling into the same category of "Low Income to Middle-Income". Browsing among the causes of death in each age group, it’s sobering to see how respiratory illness remains a big killer in young adolescents and how road traffic accidents, violence and drowning then climb up the list.
893 The global burden of disease in children has been much better studied, because of the aim to reduce mortality in the under-5s by two-thirds of its 1990 level by 2015. Looking at children under 5, classic respiratory tract bacteria still account for hundreds of thousands of deaths. Streptococcus pneumoniae remains captain of the men of death (Osler’s phrase, I think, but which he applied to older people) in children aged 1-59 months. Vaccination and prompter treatment should reduce this by at least the desired two-thirds.
903 In the case of Haemophilus influenzae type b, the use of vaccine should result in far more dramatic reductions in the current mortality of perhaps 371,000 children annually. Most of this is accounted for by Hib pneumonia and meningitis. Looking at papers like this, it’s clear that most improvements must come from political change and better herd immunity. But I wonder if there are other easily harnessed ways to help individuals in the poorer world, especially the sharing of knowledge, so abundant in the age of the internet, and yet so disorganised.
BMJ 12 Sep 2009 Vol 339
606 A couple of papers in this week’s BMJ look at the effect of diet and exercise on knee pain based on a study in five Nottinghamshire practices where overweight and obese patients were randomised to a dietary intervention, exercise, both, or neither with an advice leaflet. Quadriceps exercises done at home over two years definitely reduce pain and improve function in this group. The tagged-on economic evaluation seems to me like a waste of time.
613 But then you’d expect that from an old cynic whose first contribution to the BMJ included sarcastic comments about bran. This primary care study of insoluble fibre (i.e. bran) versus soluble fibre (something called psyllium) for irritable bowel syndrome concludes that bran is indeed better consigned to tubs than bowels. While on the other hand psyllium works for IBS, despite its psilly name.
616 “Ovarian cancer is not silent, rather its sound is going unheard.” When it first appeared on the BMJ website, this rhetorical flourish at the end of a study of early symptoms of ovarian cancer in primary care set off a predictable round of GP-bashing in the press and shroud-waving by cancer charities. I do not like ovarian cancer, because it killed my mother in a rather horrible way. She developed abdominal bloating and recurrent urinary infections as she was looking after my father in the final stages of his heart failure. In the end I had to suggest to her GP that an ultrasound scan might be useful, and when it revealed stage 4 cancer it never occurred to me to blame him for not spotting it 3 months earlier (the average delay in this study). What possible difference could that make? The paper’s ending is not present in the pico printed version, but it should read: Ovarian cancer is not silent, rather its sound is only audible when it is too late.
620 In the US television series House, the limping old grouch bats around possible diagnoses at his unhappy entourage, inevitably including strange infections and poisons, lupus, paraneoplasia and sarcoidosis. How unlike the home life of our own dear general practitioners. We might see erythema nodosum once or twice a year, uveitis a bit more often, and incidental hilar lymphadenopathy on chest X rays every now and again. Unlike our prestigious academic colleagues, we tend to have a limited interest in diseases without a known cause or specific treatment. But for a readable update, this is certainly a good place to look.
Plant of the Week: Perovskia “Blue Spire”
Although autumn is a season we tend to associate with browns and reds, there are lots of blue flowers to be had as well, on clematis species, ceratostigma, hibiscus and on this hybrid sub-shrub. Despite its name, its spires are more lavender than true blue, like those of its parents, Perovskia abrotanoides and P atriplicifolia. Once the first frosts have browned off its grey-green cut foliage, cut it well back and it will give better pleasure next year from its lovely spring growth and its beautiful flower spikes from late summer till late autumn.